Sunday, 14 September 2014

THE QUALITY OF HEALTH CARE IN AFRICA

A surprise press conference held last month by Emory University Teaching Hospital stands out as a rare bright moment in the fight against an uncontrollable Ebola virus outbreak in West Africa. ZMAPP, an untested serum-based therapy in humans, was successfully administered to two American health workers who were later declared free from the virus, which has killed more than 1500 people. While more trials were still needed to ascertain the effectiveness of the drug, the public announcement raised hopes for a new front in the fight against the ravaging epidemic. Besides treatments for its debilitating fever and bleeding symptoms, including palliative care as well as public health measures to contain the disease—such as quarantining—no licensed cures exist so far. This most deadly outbreak kills on average six out of ten patients, one more than all previous outbreaks together since 1976, when the virus first emerged. The number could climb to nine out of ten patients at the extreme. The response so far has been described as ‘'lethally inadequate’ with the World Health Organization warning that the outbreak will get worse before getting better.

Besides the ethical and equity challenges present in distributing the limited quantity of the experimental therapies, the remarkable survival and first-rate quality of treatments provided to the American patients, as well as the water-tight public health containment measures employed, paint in a very stark manner the contours of divisions in global health, which were already widening before Ebola and have been worsen by the outbreak. The emergency-only response by African countries and the international community would fail to bridge those divisions that will continue in future to manufacture new and remerging epidemics like Ebola at an alarming rate as well as with frightening impact on a global scale.

HAVES AND HAVE-NOTS

Ebola outbreak and spread are not entirely random. Outbreaks have occurred only in poor countries, where health systems are broken at best or absent at worst. A child who survives Ebola in Guinea—the epicenter of the current outbreak—would be lucky to escape premature death from cholera or other preventable diseases before the fifth birthday, and even more so, extremely lucky to live to the age of Nancy Writebol (58 years), one of the American survivors. In Sierra Leone the life expectancy is far lower: 49 years. Often the mother will not even make it past childbirth, due to inadequate or lack of prenatal or postnatal care. This pales in comparison to the situation of the US and other western countries. Thanks to their excellent health care, a child born today in those countries may live to more than double the age of peers in the Ebola-affected countries.

The contrast is even starker. The care received by the infected Americans is worlds apart from that in Ebola-hit countries. Out of the four westerners who have been infected, only one has died, two have fully recovered and the other is making encouraging progress. While the effectiveness of the unregistered treatments remains unproven in human populations, this is clear: none of the health workers in the west have been contaminated by the virus, compared to an approximately 25 per cent chance of health care workers in Africa being accidentally contaminated with the virus. So far, more than 280 health workers have died from hospital-based transmission of Ebola.

In fact, the superior quality of care provided to the Americans speaks for itself. For Dr Brantly alone, there were five world-class doctors and 21 motivated nurses to care for him. In Sierra Leone, before Ebola, there was one doctor to care for more than 23,000 patients. And now with Ebola, the number of patients would have gone even higher due to acute shortage of doctors. In Sierra Leone, The New York Times reports of one doctor caring for 90 Ebola patients.

A life in the west apparently is worth far more than one in Africa. Yearly, the US spends almost $49,668 on each citizen for healthcare, which is 776 times greater than what is spent on average for citizens in the Ebola-hit countries. The gap is getting wider, even against rising economic growth performance of over 5 per cent on the continent. African governments have been stingy when it comes to healthcare, budgets have stayed almost flat (grown by 1 per cent) over the last decade, with the continental spending hovering around 9 per cent of overall governments’ spending, which means, as a whole, that the continent will likely miss its own target of 15 per cent of public spending on healthcare (Sambo et al 2013). As a consequence, most African countries are going to miss the United Nations Millennium Development Goals (MDG) targets for reducing maternal mortality, and almost all of them will fail to cut the amount of people without access to proper sanitation, a main transmission medium for Ebola. The inequities stand out shockingly. Health is the biggest priority in the west, worth over 10 per cent of gross domestic product, compared to less than 5 per cent in Africa.

PREPAYMENTS AND PAY AS YOU GO

An even more shocking contrast is the mechanism for financing health care. The cost of healthcare is pooled and shared by the healthy members of the insured population. The infected westerners did not wait to pay for their healthcare after the Ebola-virus attack. They had been paying regularly in advance against the possibility of falling sick, even when they were healthy and chances of sickness marginal. The repatriation of the sick Americans was covered by their prepaid private health insurance. And for the Briton and the Spaniard, their cost was fully covered by prepaid contribution to their national health insurance systems. In fact, all of them have drawn on some sort of ‘equity’ to get first rate health care.

In contrast, health financing mechanisms at the demand side are very inefficient at worst and suboptimal at best in Africa. Payments for health services are largely done at the point of use with catastrophic consequences for at the very least millions of Africans. While progress has been made in some countries to institute health insurance, coverage is mostly limited to workers with formal employment, leaving behind almost 80 per cent of the populations in the informal sector. Expensive out-of-pocket spending on health care is one of the most effective poverty traps and the easiest route into deprivation[1]. Guinea, as an example, spends $32 per citizen on healthcare, and out of that amount, almost 90 per cent is from individual payments, one of the highest rates in the continent. According to the World Health Organization (WHO), two years after Burundi introduced user fees for healthcare in 2002, four out of five patients in that country were either in debt or had sold assets to pay for healthcare. Most of the populations in the Ebola-hit countries spend over 40 per cent of their income after food purchases to buy medicines and pay for health services. The risk of financial catastrophe is unmanageable, unjust and unfair.

The underinvestment translates into poor quality of services. Health care workers are among the most marginalized category of professionals in Africa. While political assassinations are often one-off events in Africa, doctors and nurses are endangered on a daily basis due to their poor working conditions. The already limited health workers are therefore pushed out of the continent to Europe and America where their skills are valued more. More than 50 per cent of Sierra Leoneans doctors work abroad. Even when health workers raise their voices, politicians rarely care. Nigerian doctors were on strike during the last two months because of low salaries [2]. And the consequences are dire for the population. For example, Africa accounts for 24 per cent of all diseases in the world but only has 3 per cent of the world’s health workforce. Guinea, the epicenter of the outbreak, has only 331 laboratory workers to cater to its 10 million people, approximately one staff member for every 30,000 people. Little wonder that the outbreak is suspected to have occurred earlier than December and was only reported four months after, when it could have been easily contained [3].

PATIENTS AND CONSUMERS

Poverty comes with neglect. Africa’s endemic diseases like Ebola affect mostly its bottom millions. As such, the patients do not form a viable consumer base enough to motivate pharmaceutical industry to invest in innovative drugs and treatments for them. The WHO has put together a list of 17 neglected poverty-related diseases (NTDs). Because those diseases exclusively affect populations in developing countries, interest from the global research community is very low and support from African governments is sadly inadequate. According to one study, of the about 1,393 new chemical entities introduced between 1975 and 1999, only 16 targeted NTDs (Trouiller 2002).

On a global scale, research for health in Africa remains marginal. In 2012, the global total investment in health research and development –including both the public and the private sector— roughly stood at $240 billion, with 89.5 per cent ($214 billion) coming from high-income countries, 7.9 per cent ($19 billion) from upper-middle-income countries, 2.6 per cent ($6.2 billion) from lower-middle-income countries, and only 0.1 per cent ($0.2 billion) from low-income countries (Røttingen 2013). Ability to conduct research on infected Ebola samples is limited to only high containment laboratories found in Europe and America.

But Ebola is unlike any other neglected disease, albeit no licensed cure exists since it emerged more than three decades ago. The imperative to overcome market failure has attracted increasingly significant public finance. The possibility of terrorists playing with an Ebola-like bug has invited national security institutions into the search for antidotes. While the US Military has no biological weapon program, it is investing heavily in research against new and emerging viruses that could threaten the health of its troops. For example, the US Military provided substantial funding to the private company that developed the experimental antiviral therapy ZMAPP, provided to the two American health workers infected in Liberia.

INTELLECTUAL PROPERTY AND HUMAN RIGHTS

How the combination of public and private partnership would translate into affordable or universal access to potential therapies remains unclear. While market failure has been a main reason behind the neglect, the unprecedented global attention and renewed interest by the pharmaceutical industry pose an intellectual property right challenge in future. Tekmira, a Canadian company developing an experimental Ebola drug (TKM-Ebola) has seen its stock swing wildly in the last two months, on the back of the news that US regulators have lifted safety restrictions for clinical trials to progress. Short term profit-oriented investors have pushed up the company’s stock price evaluation by more than 270 per cent in August [4]. The company has received almost $140 million from the US government.

It appears the patent race is not only limited to therapeutic products. Diagnostic procedures and even viral strains are subject to patent. A rough search of the World Intellectual Property Rights database reveals almost 242 patents already on different aspects of the Ebola virus [5]. All the applications for exclusive monopoly seem to come from the west. Even the virus itself is under patent. For example, the US Centers for Disease Control owns a patent on a particular strain—not the type involved in the current outbreak— of Ebola known as ‘EboBun’, (with patent number CA2741523A1) [6] awarded in 2010.

It seems the market value of the viral materials and disease will likely rise as pharmaceutical companies rush to bank on the growing potential to maximize profits in future. In this game of profits, patients carrying the virus are a valuable raw material pool. Companies could extract the virus from them, file a claim to have invented the virus, and file monopoly rights for the exclusive use of the viral material and products derived from them.

While the possible treatments and cures available remain statistically and clinically unproven in humans, pharmaceutical companies and western governments likely have commercial and political interests to talk down expectations. Besides the logistical challenges to scale up the experimental treatments, rolling them out would however come up against ethical, equity, intellectual property, or human rights challenges as well as health systems barriers. If those experimental drugs are proven to work in the current outbreak, would those drugs be provided for free to the bottom millions of Africans at risk of infection? Would there be enough functional health systems to take the drugs to all those who need them? How would the pharmaceutical companies make a return on their investment? The answers would either close or fortify already existing walls in global health.

Moving forward, the Ebola outbreak provides an opportunity to renew efforts toward universal access to health care for Africa (UHC). UHC is part of the proposals for an inclusive long-term goal for health that will succeed the MDGs, which will expire next year. As a people-centered rather than disease-centered approach, UHC aims to address the ‘cause of causes’ of sicknesses and ill health and in doing so, it would significantly contribute to reducing the gaps in global health. This is a path Africa must fast track in order to prevent Ebola and other pandemic viruses from taking full advantage of the gaping holes in its health systems, now and in future.